Coping with errors

When you lie in bed at night and have moments of reflection about your work, what do you think about?

The patient whose abnormal blood result you didn’t spot? The time you prescribed the wrong drug dose for a patient? The child who died unexpectedly, and you wonder what you should have done differently?

Over the last 10 years, the healthcare profession has come to publicly recognise that mistakes do happen. And they happen frequently. The volume of research on types of errors and ways to prevent mistakes from happening has exploded. We are all now trained on open disclosure – where mistakes may have been brushed under the carpet; now, we are open and honest about them. More transparency. More accountability. More media reporting to detail errors.

But this is only part of the picture. Whilst the primary impact of errors is on the patient, there is a ‘second victim’, the clinician. We have all made mistakes. I’ve been a doctor for 14 years, and I’ve made plenty. But it’s hard to talk about them. Because of the shame, the embarrassment, and the feeling of failure. And it’s really not in our culture to talk about our mistakes. When I contacted indemnity organisations, I was advised not to talk publicly about any mistakes I’ve made. This sets the tone for how medics feel about these discussions.

Making a mistake can leave us with complex feelings – shame, humiliation, fear, uncertainty, guilt, and inadequacy. These feelings have an impact on our work – leading to reduced job satisfaction, impaired sleep patterns, and anxiety about making future errors. This can have an effect for months or years and contribute to overall feelings of low morale and burnout amongst medical staff.

Those of us who have made mistakes can end up replaying the situation over and over in our heads, never making any progress in thought, just simply retracing the scenarios, the error, and the consequences again and again.

Here we discuss an approach to dealing with mistakes:

Firstly, remember that mistakes happen

Perspective is important. We are human, and we will make mistakes. It is an inevitability. Consider the number of patients you see, tests you order, prescriptions you write, notes you scribble in. You cannot have a perfect batting average.

Avoid counterproductive responses

Avoiding the patient will not help

One of the best pieces of advice I have heard (I think credit is to Joe Lex for this) is to spend more time with the patients you don’t like.

‘Not liking’ might be because they are rude, unhappy, challenging, you can’t solve their problem, or, in this case, because you have made a mistake. Facing them is usually better simply than avoiding them and increasing your feelings of guilt.

Emotional repression

Don’t just suck it up and get on with things. This is not usually a sustainable plan. There can be a tendency in medicine just to pretend things are no big deal and get on with the rest of the work. Yes, there are other patients to see, but it’s always important to make time to reflect.

Circular thinking

Replaying the episode incessantly in your mind does not help. It does not change what happened. These intrusive reflections just haunt us and cause self-isolation. Recognise when this is happening to you and work to break the cycle.

Defensive medical practice

An obstetrics study identified six index cases of shoulder dystocia with intrapartum fetal deaths. In the 50 subsequent deliveries, there was a 36% increase in Caesarean sections.

It’s a natural reaction when an error occurs to do everything to prevent the error from recurring. But taking this to extremes of defensive medicine is not in the best interests of your patients and can lead to over-investigation and over-treatment.

Take positive steps

 Accept responsibility

Ok, it happened. You wrote up the wrong drug. It’s not helpful to get stuck in the mindset of blaming others or the environment (i.e. I was distracted, I was being asked to do several things at once). In the end, the recognition of your role in the error is the first step to being able to move forward.

***Having said that, the identification of a mistake can be a powerful opportunity to think about positive changes that could be made to your knowledge, your workflow or the system in which you work***.

Talk to people

Needing support is not a sign of weakness. It’s part of using our professional and personal networks to manage effectively. Talking to your family about your error can be helpful to put things in perspective and get some support from someone who loves you outside of you being a doctor. Your colleagues can also offer support – you will find that they have plenty of errors of their own to share when you open up to them. Sharing this burden and acknowledging that these things happen will help you to move on.

Your colleagues and family are not counsellors, but they can offer a friendly ear and support.

Sort the problem

If the problem is your poor suturing skills, work hard to improve them. If the issue is you missed an important ECG finding, then spend time learning about ECG interpretation.

If you have uncovered the clinical equivalent of a missing manhole cover, then tell your boss about it.  Pursuing additional training in areas of weakness will help you become a better doctor and will minimise the chances of the error being repeated.

Advocate for a culture change in medical error

It’s up to us to change the culture of medicine to support staff when errors are made. Professionals will make mistakes, and we need to take action against reckless conduct. The challenge in medicine is to balance the need to learn from our mistakes with the need to take disciplinary action and investigate mistakes when they happen.

You will make many mistakes over the course of your career. Don’t let them define you, and use them to your advantage to make you a better doctor in future.

References

Hoffman, J. Physicians coping after medical error, KevinMD, 2011.

Hall LW, Scott SD. The second victim of adverse health care events. Nursing Clinics of North America. 2012 Sep 30;47(3):383-93.

West, CP. How do providers recover from errors? AHRQ, 2008.

White, AA, Gallagher TH. After the apology – coping and recovery after errors, AMA Journal of Ethics, 2011 https://journalofethics.ama-assn.org/2011/09/ccas1-1109.html.